Patient Forms
Our fax is: 315-592-3571
PATIENT OFFICE INFORMATION (Click to Download)
If your child is seen by a specialist or other health care facilities and needs a release to have records sent to our office, use the form below to do so. This ensures that we are able to receive medical records pertaining to your next appointment.
MEDICAL INFORMATION RELEASE FORM(Click to Download)
To transfer your care or your child’s care to another practice, please download the form below, and drop off/MAIL or FAX to our office.
TRANSFER OUT FORM (Click to Download)
DAYCARE MEDICATION FORM (Click to Download)
Working Papers:
WORKING PAPER FORM (Click to Download)- you need to print on the according color paper.
** During Covid-19 shut down of schools you can print on REGULAR paper and CHECK MARK appropriate age box instead of using the color system. **
Why Do I Need Working Papers?- Working papers serve as your official employment certificate. Working papers were established to make sure businesses do not work you too many hours while you are in school and in the summer as well.
How Old Do I Have to Be to Get Working Papers? -You will need working papers if you are under 18 years old. Working papers are divided into two age groups (14-15 and 16-17):
14-15 year olds - Your working papers are blue. If you are 14 and 15 years old, you are issued these working papers because you are not allowed to work in a factory.
16-17 year olds (in school) - Your working papers are green. The difference between 14-15 year old working papers and 16-17 year old working papers is that you are allowed to work in a factory. You cannot work around certain machines, do construction work, help on a motor vehicle, clean, oil, wipe, or adjust belts on machinery.
16-17 year olds (out of school) - Your working papers are peach. If you are 16 to 17 years old and are not in school or are leaving school for full time employment, you will need these working papers. You are allowed to work in a factory, cannot work around certain machines, do construction work, help on a motor vehicle, or clean, oil, wipe, or adjust belts on machinery.
Where Do I Get My Working Papers and What Do I Need to Get Them? - You will have to take the steps described below to get your working papers
If you are in school, go to your guidance office and ask for a working papers application. If you are not in school, go to the nearest school by where you live because they are required to give you the application.
Fill out the application and have your parent or guardian sign the application.
When you have filled out the working papers application and had your parent or guardian sign it, you have to take it back to the school's guidance office.
Obtain proof of age, such as your birth certificate, a state-issued photo ID, driver's license, or passport.
You will also need to have had a doctor's exam within the last 12 months saying you are physically fit. A physical given at a school for sports will count for your physical exam. If you are not sure where you can get a physical, ask your guidance office or call your doctor.
Working Papers Tips - Below is helpful information once you have your working papers and are on the job:
When you turn 16, you will need to go from your 14-15 year old working papers (blue) and get your 16-17 year old working papers (green). Go to your guidance office of your school or nearest school to update your working papers.
Before you start work at a new job, you must give your employer the blue, green or peach employment certificate. Employers are not allowed to accept photocopies of your working papers. If you lose your working papers, you will have to go back to the school and ask for a duplicate (copy) to be issued to you.
At the end of a job, the employer must give your working papers back to you. You can use them on your next job (if you are still the right age for the certificate). If the employer does not return your working papers, you can ask the school to issue you a duplicate (copy). You can also complain to Labor Standards
Labor Laws help protect you as a worker and outline your rights. Check out some videos and workplace safety tips from the Occupational Safety & Health Administration Working Teen & Videos
Find out more about about what you can and cannot do on the job under the age of 18
River View Pediatrics HIPAA NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. TO REVIEW THE FULL DISCLOSURE PLEASE CONTACT THE OFFICE TO HAVE THE FORM EMAILED/MAILED OR TO PICK UP A COPY AT THE OFFICE.
If you have any questions about this notice please contact our Privacy Officer who is
Dr. Christopher DeLaney, 315-598-6785.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information, "Protected health information" is information about, including health information, that may identify you and that relates to your past, present, or future physical or mental health conditions and related healthcare services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised copy to be sent to you in the mail by calling our office or asking for one at the time of you next appointment.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health care information may also be used and disclosed to pay your health care bills and to support the operation of your physician's practice.